Pneumonia

Main symptoms of infectious

For other uses, see Pneumonia (disambiguation).

Pneumonia

Systemic:

Pneumonia (nu-mo'ne-a) is an inammatory condition

of the lung aecting primarily the microscopic air sacs
known as alveoli.[1][2] It is usually caused by infection with viruses or bacteria and less commonly other
microorganisms, certain drugs and other conditions such
as autoimmune diseases.[1][3]

- High fever
- Chills
Skin:
- Clamminess
- Blueness

Lungs:
- Cough with
sputum or
phlegm
- Shortness
of breath
- Pleuritic
chest pain
- Hemoptysis

Typical symptoms include a cough, chest pain, fever, and

diculty breathing.[4] Diagnostic tools include x-rays and
culture of the sputum. Vaccines to prevent certain types
of pneumonia are available. Treatment depends on the
underlying cause. Pneumonia presumed to be bacterial is
treated with antibiotics. If the pneumonia is severe, the
aected person is generally hospitalized.

Muscular:
- Fatigue
- Aches

Pneumonia aects approximately 450 million people

globally per year, seven percent of population, and results
in about 4 million deaths, mostly in developing countries.
Although pneumonia was regarded by William Osler in
the 19th century as the captain of the men of death,[5]
the advent of antibiotic therapy and vaccines in the 20th
century has seen improvements in survival.[6] Nevertheless, in developing countries, and among the very old, the
very young, and the chronically ill, pneumonia remains a
leading cause of death.[6][7] In the terminally ill and elderly, especially those with other conditions, pneumonia
is often the immediate cause of death. In such cases, particularly when it cuts short the suering associated with
lingering illness, pneumonia has often been called the
old mans friend.[8]

Central:
- Headaches
- Loss of appetite
- Mood swings
Vascular
- Low blood pressure
Heart:
- High heart rate

Gastric:
- Nausea
- Vomiting
Joints:
- Pain

Main symptoms of infectious pneumonia

sciousness.[11][12]
Bacterial and viral cases of pneumonia usually present
with similar symptoms.[13] Some causes are associated
with classic, but non-specic, clinical characteristics.
Pneumonia caused by Legionella may occur with abdominal pain, diarrhea, or confusion,[14] while pneumonia caused by Streptococcus pneumoniae is associated
with rusty colored sputum,[15] and pneumonia caused by
Klebsiella may have bloody sputum often described as
currant jelly.[9] Bloody sputum (known as hemoptysis)
may also occur with tuberculosis, Gram-negative pneumonia, and lung abscesses as well as more commonly with
acute bronchitis.[12] Mycoplasma pneumonia may occur
in association with swelling of the lymph nodes in the
neck, joint pain, or a middle ear infection.[12] Viral pneumonia presents more commonly with wheezing than does
bacterial pneumonia.[13] Pneumonia was historically divided into typical and atypical based on the belief that
the presentation predicted the underlying cause.[16] Evidence; however, has not supported this distinction, thus it
is no longer emphasized.[16]

Signs and symptoms

People with infectious pneumonia often have a productive

cough, fever accompanied by shaking chills, shortness of
breath, sharp or stabbing chest pain during deep breaths,
and an increased respiratory rate.[10] In the elderly, confusion may be the most prominent sign.[10] The typical signs
and symptoms in children under ve are fever, cough, and
fast or dicult breathing.[11]

Fever is not very specic, as it occurs in many other common illnesses, may be absent in those with severe disease, malnutrition or in the elderly. In addition, a cough 2 Cause
is frequently absent in children less than 2 months old.[11]
More severe signs and symptoms may include blue-tinged Pneumonia is due to infections caused primarily by
skin, decreased thirst, convulsions, persistent vomiting, bacteria or viruses and less commonly by fungi and
extremes of temperature, or a decreased level of con- parasites. Although there are more than 100 strains of
1

2 CAUSE
of Streptococcus pneumoniae, Haemophilus inuenzae,
Moraxella catarrhalis, and Legionella pneumophila. Exposure to birds is associated with Chlamydia psittaci;
farm animals with Coxiella burnetti; aspiration of stomach contents with anaerobic organisms; and cystic brosis with Pseudomonas aeruginosa and Staphylococcus aureus.[8] Streptococcus pneumoniae is more common in the
winter,[8] and should be suspected in persons aspirating a
large amount anaerobic organisms.[12]

The bacterium Streptococcus pneumoniae, a common cause of

pneumonia, imaged by an electron microscope.

2.2 Viruses
Main article: Viral pneumonia

infectious agents identied, only a few are responsible

for the majority of the cases. Mixed infections with both
viruses and bacteria may occur in up to 45% of infections
in children and 15% of infections in adults.[6] A causative
agent may not be isolated in approximately half of cases
despite careful testing.[8]
The term pneumonia is sometimes more broadly applied
to any condition resulting in inammation of the lungs
(caused for example by autoimmune diseases, chemical
burns or drug reactions); however, this inammation is
more accurately referred to as pneumonitis.[17][18]
Conditions and risk factors that predispose to pneumonia include smoking, immunodeciency, alcoholism,
chronic obstructive pulmonary disease, chronic kidney
disease, and liver disease.[12] The use of acid-suppressing
medicationssuch as proton-pump inhibitors or H2
blockersis associated with an increased risk of
pneumonia.[19] The risk is also increased in old age.[12]

2.1

Bacteria

In adults, viruses account for approximately a third[6]

and in children for about 15% of pneumonia cases.[22]
Commonly implicated agents include rhinoviruses,
coronaviruses, inuenza virus, respiratory syncytial
virus (RSV), adenovirus, and parainuenza.[6][23]
Herpes simplex virus rarely causes pneumonia, except
in groups such as: newborns, persons with cancer,
transplant recipients, and people with signicant
burns.[24] People following organ transplantation or
those otherwise-immunocompromised present high rates
of cytomegalovirus pneumonia.[22][24] Those with viral
infections may be secondarily infected with the bacteria
Streptococcus pneumoniae, Staphylococcus aureus, or
Haemophilus inuenzae, particularly when other health
problems are present.[12][22] Dierent viruses predominate at dierent periods of the year; during inuenza
season, for example, inuenza may account for over
half of all viral cases.[22] Outbreaks of other viruses
also occasionally occur, including hantaviruses and
coronavirus.[22]

Main article: Bacterial pneumonia

Bacteria are the most common cause of communityacquired pneumonia (CAP), with Streptococcus pneumoniae isolated in nearly 50% of cases.[20][21] Other
commonly isolated bacteria include Haemophilus inuenzae in 20%, Chlamydophila pneumoniae in 13%,
and Mycoplasma pneumoniae in 3% of cases;[20]
Staphylococcus aureus; Moraxella catarrhalis; Legionella
pneumophila and Gram-negative bacilli.[8] A number of
drug-resistant versions of the above infections are becoming more common, including drug-resistant Streptococcus
pneumoniae (DRSP) and methicillin-resistant Staphylococcus aureus (MRSA).[12]
The spreading of organisms is facilitated when risk factors are present.[8] Alcoholism is associated with Streptococcus pneumoniae, anaerobic organisms, and Mycobacterium tuberculosis; smoking facilitates the eects

2.3 Fungi
Main article: Fungal pneumonia
Fungal pneumonia is uncommon, but occurs more
commonly in individuals with weakened immune systems due to AIDS, immunosuppressive drugs, or other
medical problems.[8][25] It is most often caused by
Histoplasma capsulatum, blastomyces, Cryptococcus neoformans, Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis is most common in the Mississippi
River basin, and coccidioidomycosis is most common in
the Southwestern United States.[8] The number of cases
have been increasing in the later half of the 20th century
due to increasing travel and rates of immunosuppression
in the population.[25]

3.2

2.4

Bacterial

Parasites

Main article: Parasitic pneumonia

A variety of parasites can aect the lungs, including
Toxoplasma gondii, Strongyloides stercoralis, Ascaris lumbricoides, and Plasmodium malariae.[26] These organisms typically enter the body through direct contact with
the skin, ingestion, or via an insect vector.[26] Except
for Paragonimus westermani, most parasites do not affect specically the lungs but involve the lungs secondarily to other sites.[26] Some parasites, in particular those belonging to the Ascaris and Strongyloides
genera, stimulate a strong eosinophilic reaction, which
may result in eosinophilic pneumonia.[26] In other infections, such as malaria, lung involvement is due primarily to cytokine-induced systemic inammation.[26] In the
developed world these infections are most common in
people returning from travel or in immigrants.[26] Around
the world, these infections are most common in the
immunodecient.[27]

2.5

Idiopathic

Pneumonia lls the lungs alveoli with uid, hindering oxygenation. The alveolus on the left is normal, whereas the one on the
right is full of uid from pneumonia.

Main article: Idiopathic interstitial pneumonia

Idiopathic interstitial pneumonia or noninfectious
pneumonia[28] are a class of diuse lung diseases. They
include diuse alveolar damage, organizing pneumonia,
nonspecic interstitial pneumonia, lymphocytic interstitial pneumonia, desquamative interstitial pneumonia,
respiratory bronchiolitis interstitial lung disease, and
usual interstitial pneumonia.[29]

Mechanisms

white blood cells, mainly mononuclear cells, generate the

inammation.[31] As well as damaging the lungs, many
viruses simultaneously aect other organs and thus disrupt other body functions. Viruses also make the body
more susceptible to bacterial infections; in this way, bacterial pneumonia can arise as a co-morbid condition.[23]

3.2 Bacterial

Pneumonia frequently starts as an upper respiratory tract

Most bacteria enter the lungs via small aspirations of orinfection that moves into the lower respiratory tract.[30]
ganisms residing in the throat or nose.[12] Half of normal people have these small aspirations during sleep.[16]
3.1 Viral
While the throat always contains bacteria, potentially infectious ones reside there only at certain times and unViruses may reach the lung by a number of dierent der certain conditions.[16] A minority of types of bacroutes. Respiratory syncytial virus is typically contracted teria such as Mycobacterium tuberculosis and Legionella
when people touch contaminated objects and then they pneumophila reach the lungs via contaminated airborne
touch their eyes or nose.[22] Other viral infections oc- droplets.[12] Bacteria can spread also via the blood.[13]
cur when contaminated airborne droplets are inhaled Once in the lungs, bacteria may invade the spaces bethrough the mouth or nose.[12] Once in the upper air- tween cells and between alveoli, where the macrophages
way, the viruses may make their way in the lungs, where and neutrophils (defensive white blood cells) attempt to
they invade the cells lining the airways, alveoli, or lung inactivate the bacteria.[32] The neutrophils also release
parenchyma.[22] Some viruses such as measles and her- cytokines, causing a general activation of the immune
pes simplex may reach the lungs via the blood.[31] The system.[33] This leads to the fever, chills, and fatigue cominvasion of the lungs may lead to varying degrees of cell mon in bacterial pneumonia.[33] The neutrophils, bactedeath.[22] When the immune system responds to the in- ria, and uid from surrounding blood vessels ll the alvefection, even more lung damage may occur.[22] Primarily oli, resulting in the consolidation seen on chest X-ray.[34]

4 DIAGNOSIS

Diagnosis

Pneumonia is typically diagnosed based on a combination

of physical signs and a chest X-ray.[35] However, the underlying cause can be dicult to conrm, as there is no
denitive test able to distinguish between bacterial and
non-bacterial origin.[6][35] The World Health Organization has dened pneumonia in children clinically based
on either a cough or diculty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of
consciousness.[36] A rapid respiratory rate is dened as
greater than 60 breaths per minute in children under 2
months old, 50 breaths per minute in children 2 months
to 1 year old, or greater than 40 breaths per minute in CT of the chest demonstrating right-side pneumonia (left side of
children 1 to 5 years old.[36] In children, increased respi- the image).
ratory rate and lower chest indrawing are more sensitive
than hearing chest crackles with a stethoscope.[11]
separate between bacterial infection and
In general, in adults, investigations are not needed in mild do not reliably[11]
viral
infection.
[37]
cases:
There is a very low risk of pneumonia if all
vital signs and auscultation are normal.[38] In persons requiring hospitalization, pulse oximetry, chest radiography and blood testsincluding a complete blood count,
serum electrolytes, C-reactive protein level, and possibly
liver function testsare recommended.[37] The diagnosis
of inuenza-like illness can be made based on the signs
and symptoms; however, conrmation of an inuenza infection requires testing.[39] Thus, treatment is frequently
based on the presence of inuenza in the community or a
rapid inuenza test.[39]

X-ray presentations of pneumonia may be classied as

lobar pneumonia, bronchopneumonia (also known as lobular pneumonia), and interstitial pneumonia.[40] Bacterial, community-acquired pneumonia classically show
lung consolidation of one lung segmental lobe, which is
known as lobar pneumonia.[20] However, ndings may
vary, and other patterns are common in other types of
pneumonia.[20] Aspiration pneumonia may present with
bilateral opacities primarily in the bases of the lungs
and on the right side.[20] Radiographs of viral pneumonia
may appear normal, appear hyper-inated, have bilateral
patchy areas, or present similar to bacterial pneumonia
4.1 Physical exam
with lobar consolidation.[20] Radiologic ndings may not
be present in the early stages of the disease, especially
Physical examination may sometimes reveal low blood in the presence of dehydration, or may be dicult to be
pressure, high heart rate, or low oxygen saturation.[12] interpreted in the obese or those with a history of lung
The respiratory rate may be faster than normal, and this disease.[12] A CT scan can give additional information in
may occur a day or two before other signs.[12][16] Ex- indeterminate cases.[20]
amination of the chest may be normal, but it may show
decreased chest expansion on the aected side. Harsh
breath sounds from the larger airways that are transmitted
through the inamed lung are termed bronchial breath- 4.3 Microbiology
ing and are heard on auscultation with a stethoscope.[12]
Crackles (rales) may be heard over the aected area dur- In patients managed in the community, determining the
ing inspiration.[12] Percussion may be dulled over the af- causative agent is not cost-eective and typically does not
fected lung, and increased, rather than decreased, vocal alter management.[11] For people that do not respond to
resonance distinguishes pneumonia from a pleural eu- treatment, sputum culture should be considered, and culture for Mycobacterium tuberculosis should be carried out
sion.[10]
in persons with a chronic productive cough.[37] Testing
for other specic organisms may be recommended dur4.2 Imaging
ing outbreaks, for public health reasons.[37] In those hospitalized for severe disease, both sputum and blood culA chest radiograph is frequently used in diagnosis.[11] tures are recommended,[37] as well as testing the urine for
In people with mild disease, imaging is needed only in antigens to Legionella and Streptococcus.[41] Viral infecthose with potential complications, those not having im- tions can be conrmed via detection of either the virus
proved with treatment, or those in which the cause is or its antigens with culture or polymerase chain reaction
uncertain.[11][37] If a person is suciently sick to require (PCR), among other techniques.[6] The causative agent is
hospitalization, a chest radiograph is recommended.[37] determined in only 15% of cases with routine microbioFindings do not always match the severity of disease and logical tests.[10]

5.2

4.4

Other

Classication

Main article: Classication of pneumonia

5
pany that manufactures oseltamivir has refused to release
the trial data for independent analysis.[48]
Vaccinations against Haemophilus inuenzae and
Streptococcus pneumoniae have good evidence to support
their use.[30] Vaccinating children against Streptococcus
pneumoniae has led to a decreased incidence of these infections in adults, because many adults acquire infections
from children. A Streptococcus pneumoniae vaccine is
available for adults, and has been found to decrease the
risk of invasive pneumococcal disease.[49] Other vaccines
for which there to support for a protective eect against
pneumonia include pertussis, varicella, and measles.[50]

Pneumonitis refers to lung inammation; pneumonia refers to pneumonitis, usually due to infection
but sometimes non-infectious, that has the additional
feature of pulmonary consolidation.[42] Pneumonia is
most commonly classied by where or how it was
acquired: community-acquired, aspiration, healthcareassociated, hospital-acquired, and ventilator-associated
pneumonia.[20] It may also be classied by the area of
lung aected: lobar pneumonia, bronchial pneumonia
and acute interstitial pneumonia;[20] or by the causative
organism.[43] Pneumonia in children may additionally be 5.2 Other
classied based on signs and symptoms as non-severe, seSmoking cessation[37] and reducing indoor air pollution,
vere, or very severe.[44]
such as that from cooking indoors with wood or dung,
are both recommended.[11][13] Smoking appears to be the
single biggest risk factor for pneumococcal pneumonia
4.5 Dierential diagnosis
in otherwise-healthy adults.[41] Hand hygiene and coughsleeve may also be eective preventative
Several diseases can present with similar signs and symp- ing into ones
[50]
measures.
Wearing
surgical masks by the sick may also
toms to pneumonia, such as: chronic obstructive pul[41]
prevent
illness.
monary disease (COPD), asthma, pulmonary edema,
bronchiectasis, lung cancer, and pulmonary emboli.[10]
Unlike pneumonia, asthma and COPD typically present
with wheezing, pulmonary edema presents with an abnormal electrocardiogram, cancer and bronchiectasis present
with a cough of longer duration, and pulmonary emboli
presents with acute onset sharp chest pain and shortness
of breath.[10]

Prevention

Prevention includes vaccination, environmental measures

and appropriate treatment of other health problems.[11] It
is believed that, if appropriate preventive measures were
instituted globally, mortality among children could be reduced by 400,000; and, if proper treatment were universally available, childhood deaths could be decreased by
another 600,000.[13]

5.1

Vaccination

Vaccination prevents against certain bacterial and viral pneumonias both in children and adults. Inuenza
vaccines are modestly eective against inuenza A and
B.[6][45] The Center for Disease Control and Prevention
(CDC) recommends yearly vaccination for every person
6 months and older.[46] Immunizing health care workers decreases the risk of viral pneumonia among their
patients.[41] When inuenza outbreaks occur, medications such as amantadine or rimantadine may help prevent the condition.[47] It is unknown whether zanamivir
or oseltamivir is eective due to the fact that the com-

Appropriately treating underlying illnesses (such as

HIV/AIDS, diabetes mellitus, and malnutrition) can decrease the risk of pneumonia.[13][50][51] In children less
than 6 months of age, exclusive breast feeding reduces
both the risk and severity of disease.[13] In those with
HIV/AIDS and a CD4 count of less than 200 cells/uL
the antibiotic trimethoprim/sulfamethoxazole decreases
the risk of Pneumocystis pneumonia[52] and may also be
useful for prevention in those that are immunocomprised
but do not have HIV.[53]
Testing pregnant women for Group B Streptococcus
and Chlamydia trachomatis, and administering antibiotic
treatment, if needed, reduces rates of pneumonia in
infants;[54][55] preventive measures for HIV transmission
from mother to child may also be ecient.[56] Suctioning
the mouth and throat of infants with meconium-stained
amniotic uid has not been found to reduce the rate of
aspiration pneumonia and may cause potential harm,[57]
thus this practice is not recommended in the majority of
situations.[57] In the frail elderly good oral health care may
lower the risk of aspiration pneumonia.[58]

6 Management
Oral antibiotics, rest, simple analgesics, and uids usually suce for complete resolution.[37] However, those
with other medical conditions, the elderly, or those
with signicant trouble breathing may require more advanced care. If the symptoms worsen, the pneumonia
does not improve with home treatment, or complications occur, hospitalization may be required.[37] Worldwide, approximately 713% of cases in children result

in hospitalization,[11] whereas in the developed world between 22 and 42% of adults with community-acquired
pneumonia are admitted.[37] The CURB-65 score is useful for determining the need for admission in adults.[37]
If the score is 0 or 1, people can typically be managed at
home; if it is 2, a short hospital stay or close follow-up is
needed; if it is 35, hospitalization is recommended.[37]
In children those with respiratory distress or oxygen saturations of less than 90% should be hospitalized.[59] The
utility of chest physiotherapy in pneumonia has not yet
been determined.[60] Non-invasive ventilation may be
benecial in those admitted to the intensive care unit.[61]
Over-the-counter cough medicine has not been found to
be eective[62] nor has the use of zinc in children.[63]
There is insucient evidence for mucolytics.[62]

6.1

Bacterial

Antibiotics improve outcomes in those with bacterial

pneumonia.[64] Antibiotic choice depends initially on the
characteristics of the person aected, such as age, underlying health, and the location the infection was acquired. In the UK, empiric treatment with amoxicillin
is recommended as the rst line for communityacquired pneumonia, with doxycycline or clarithromycin
as alternatives.[37] In North America, where the atypical
forms of community-acquired pneumonia are more common, macrolides (such as azithromycin or erythromycin),
and doxycycline have displaced amoxicillin as rst-line
outpatient treatment in adults.[21][65] In children with
mild or moderate symptoms, amoxicillin remains the
rst line.[59] The use of uoroquinolones in uncomplicated cases is discouraged due to concerns about
side-eects and generating resistance in light of there
being no greater clinical benet.[21][66] The duration
of treatment has traditionally been seven to ten days,
but increasing evidence suggests that shorter courses
(three to ve days) are similarly eective.[67] Recommended for hospital-acquired pneumonia include thirdand fourth-generation cephalosporins, carbapenems,
uoroquinolones, aminoglycosides, and vancomycin.[68]
These antibiotics are often given intravenously and used
in combination.[68] In those treated in hospital, more than
90% improve with the initial antibiotics.[16]

6.2

PROGNOSIS

strains of H5N1 inuenza A, also known as avian inuenza or bird u, have shown resistance to rimantadine and amantadine.[6] The use of antibiotics in viral
pneumonia is recommended by some experts, as it is impossible to rule out a complicating bacterial infection.[6]
The British Thoracic Society recommends that antibiotics be withheld in those with mild disease.[6] The use
of corticosteroids is controversial.[6]

6.3 Aspiration
In general, aspiration pneumonitis is treated conservatively with antibiotics indicated only for aspiration pneumonia.[69] The choice of antibiotic will depend on several factors, including the suspected causative organism
and whether pneumonia was acquired in the community or developed in a hospital setting. Common options include clindamycin, a combination of a beta-lactam
antibiotic and metronidazole, or an aminoglycoside.[70]
Corticosteroids are sometimes used in aspiration pneumonia, but there is limited evidence to support their
eectiveness.[69]

7 Prognosis
With treatment, most types of bacterial pneumonia will
stabilize in 36 days.[71] It often takes a few weeks before most symptoms resolve.[71] X-ray nding typically
clear within four weeks and mortality is low (less than
1%).[12][72] In the elderly or people with other lung problems, recovery may take more than 12 weeks. In persons requiring hospitalization, mortality may be as high
as 10%, and in those requiring intensive care it may reach
3050%.[12] Pneumonia is the most common hospitalacquired infection that causes death.[16] Before the advent
of antibiotics, mortality was typically 30% in those that
were hospitalized.[8]
Complications may occur in particular in the elderly
and those with underlying health problems.[72] This
may include, among others: empyema, lung abscess,
bronchiolitis obliterans, acute respiratory distress syndrome, sepsis, and worsening of underlying health
problems.[72]

Viral
7.1 Clinical prediction rules

Neuraminidase inhibitors may be used to treat viral

pneumonia caused by inuenza viruses (inuenza A and
inuenza B).[6] No specic antiviral medications are recommended for other types of community acquired viral pneumonias including SARS coronavirus, adenovirus,
hantavirus, and parainuenza virus.[6] Inuenza A may
be treated with rimantadine or amantadine, while inuenza A or B may be treated with oseltamivir, zanamivir
or peramivir.[6] These are of most benet if they are
started within 48 hours of the onset of symptoms.[6] Many

Clinical prediction rules have been developed to more objectively predict outcomes of pneumonia.[16] These rules
are often used in deciding whether or not to hospitalize
the person.[16]
Pneumonia severity index (or PSI Score)[16]
CURB-65 score, which takes into account the severity of symptoms, any underlying diseases, and

7
age[73]

7.2

periods of mechanical ventilation for survival.[22]

Sepsis is a potential complication of pneumonia but

Pleural eusion, empyema, and ab- occurs usually in people with poor immunity or
hyposplenism. The organisms most commonly involved
scess
are Streptococcus pneumoniae, Haemophilus inuenzae,
and Klebsiella pneumoniae. Other causes of the symptoms should be considered such as a myocardial infarction
or a pulmonary embolism.[75]

8 Epidemiology
Main article: Epidemiology of pneumonia
Pneumonia is a common illness aecting approximately

A pleural eusion: as seen on chest X-ray. The A arrow indicates

uid layering in the right chest. The B arrow indicates the width
of the right lung. The volume of the lung is reduced because of
the collection of uid around the lung.

In pneumonia, a collection of uid may form in the space

that surrounds the lung.[74] Occasionally, microorganisms will infect this uid, causing an empyema.[74] To
distinguish an empyema from the more common simple
parapneumonic eusion, the uid may be collected with
a needle (thoracentesis), and examined.[74] If this shows
evidence of empyema, complete drainage of the uid is
necessary, often requiring a drainage catheter.[74] In severe cases of empyema, surgery may be needed.[74] If the
infected uid is not drained, the infection may persist,
because antibiotics do not penetrate well into the pleural
cavity. If the uid is sterile, it must be drained only if it
is causing symptoms or remains unresolved.[74]
In rare circumstances, bacteria in the lung will form
a pocket of infected uid called a lung abscess.[74]
Lung abscesses can usually be seen with a chest Xray but frequently require a chest CT scan to conrm
the diagnosis.[74] Abscesses typically occur in aspiration
pneumonia, and often contain several types of bacteria.
Long-term antibiotics are usually adequate to treat a lung
abscess, but sometimes the abscess must be drained by a
surgeon or radiologist.[74]

7.3

Respiratory and circulatory failure

Pneumonia can cause respiratory failure by triggering

acute respiratory distress syndrome (ARDS), which results from a combination of infection and inammatory
response. The lungs quickly ll with uid and become
sti. This stiness, combined with severe diculties extracting oxygen due to the alveolar uid, may require long

Age-standardized death rate: lower respiratory tract infections

per 100,000 inhabitants in 2004.[76]

450 million people a year and occurring in all parts of

the world.[6] It is a major cause of death among all age
groups resulting in 4 million deaths (7% of the worlds
total death) yearly.[6][64] Rates are greatest in children
less than ve, and adults older than 75 years.[6] It occurs
about ve times more frequently in the developing world
than in the developed world.[6] Viral pneumonia accounts
for about 200 million cases.[6] In the United States, as of
2009, pneumonia is the 8th leading cause of death.[12]

8.1 Children
In 2008, pneumonia occurred in approximately 156 million children (151 million in the developing world and
5 million in the developed world).[6] In 2010, it resulted
in 1.3 million deaths, or 18% of all deaths in those under ve years, of which 95% occurred in the developing
world.[6][11][77] Countries with the greatest burden of disease include India (43 million), China (21 million) and
Pakistan (10 million).[78] It is the leading cause of death
among children in low income countries.[6][64] Many of
these deaths occur in the newborn period. The World
Health Organization estimates that one in three newborn
infant deaths is due to pneumonia.[79] Approximately half
of these deaths can be prevented, as they are caused by the
bacteria for which an eective vaccine is available.[80] In
2011, pneumonia was the most common reason for admission to the hospital after an emergency department
visit in the U.S. for infants and children.[81]

10 SOCIETY AND CULTURE

History

ways of persons having died of pneumonia in 1875.[85]

Initial work identifying the two common bacterial
causes, Streptococcus pneumoniae and Klebsiella pneumoniae, was performed by Carl Friedlnder[86] and Albert
Frnkel[87] in 1882 and 1884, respectively. Friedlnders
initial work introduced the Gram stain, a fundamental
laboratory test still used today to identify and categorize
bacteria. Christian Gram's paper describing the procedure in 1884 helped to dierentiate the two bacteria, and
showed that pneumonia could be caused by more than one
microorganism.[88]
Sir William Osler, known as the father of modern
medicine, appreciated the death and disability caused
by pneumonia, describing it as the captain of the men
of death in 1918, as it had overtaken tuberculosis as one
of the leading causes of death in this time. This phrase
was originally coined by John Bunyan in reference to
consumption (tuberculosis).[89][90] Osler also described
pneumonia as the old mans friend as death was often
quick and painless when there were many slower more
painful ways to die.[8]

Several developments in the 1900s improved the outcome for those with pneumonia. With the advent of
penicillin and other antibiotics, modern surgical techniques, and intensive care in the 20th century, mortality from pneumonia, had approached 30%, dropped precipitously in the developed world. Vaccination of infants
against Haemophilus inuenzae type B began in 1988 and
led to a dramatic decline in cases shortly thereafter.[91]
Vaccination against Streptococcus pneumoniae in adults
WPA poster, 1936/1937
began in 1977, and in children in 2000, resulting in a sim[92]
Pneumonia has been a common disease throughout ilar decline.
human history.[82] The symptoms were described by
Hippocrates (c. 460 BC 370 BC):[82] Peripneumonia,
and pleuritic aections, are to be thus observed: If the 10 Society and culture
fever be acute, and if there be pains on either side, or in
both, and if expiration be if cough be present, and the
See also: List of notable pneumonia cases
sputa expectorated be of a blond or livid color, or likewise thin, frothy, and orid, or having any other character dierent from the common... When pneumonia
is at its height, the case is beyond remedy if he is not 10.1 Awareness
purged, and it is bad if he has dyspnoea, and urine that
is thin and acrid, and if sweats come out about the neck
Due to the high burden of disease in developing countries
and head, for such sweats are bad, as proceeding from
and a relatively low awareness of the disease in develthe suocation, rales, and the violence of the disease
oped countries, the global health community has declared
which is obtaining the upper hand.[83] However, Hip12 November as World Pneumonia Day, a day for conpocrates referred to pneumonia as a disease named by
cerned citizens and policy makers to take action against
the ancients. He also reported the results of surgical
the disease.[93]
drainage of empyemas. Maimonides (11351204 AD)
observed: The basic symptoms that occur in pneumonia and that are never lacking are as follows: acute fever, 10.2 Costs
sticking pleuritic pain in the side, short rapid breaths, serrated pulse and cough.[84] This clinical description is The global economic cost of community-acquired pneuquite similar to those found in modern textbooks, and monia has been estimated at $17 billion annually.[12]
it reected the extent of medical knowledge through the Other estimates are considerably higher. In 2012 the
Middle Ages into the 19th century.
estimated aggregate costs of treating pneumonia in the
Edwin Klebs was the rst to observe bacteria in the air- United States were $20 billion;[94] the median cost

9
of a single pneumonia-related hospitalization is over [12] Nair, GB; Niederman, MS (November 2011).
Community-acquired pneumonia:
an unnished
$15,000.[95] According to data released by the Centers for
battle. The Medical clinics of North America 95 (6):
Medicare and Medicaid Services, average 2012 hospital
114361. doi:10.1016/j.mcna.2011.08.007. PMID
charges for inpatient treatment of uncomplicated pneu22032432.
monia in the U.S. were $24,549 and ranged as high as
$124,000. The average cost of an emergency room con[13] Pneumonia (Fact sheet N331)". World Health Organisult for pneumonia was $943 and the average cost for
zation. August 2012.
medication was $66.[96] Aggregate annual costs of treating pneumonia in Europe have been estimated at 10 [14] Darby, J; Buising, K (October 2008). Could it be Lebillion.[97]
gionella?". Australian family physician 37 (10): 8125.
PMID 19002299.

11

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Burke A. Cunha, ed. (2010). Pneumonia essentials
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12

External links

Pneumonia at DMOZ

14

13

13
13.1

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Khaosworks, DragonySixtyseven, Kevin B12, Bk0, Sam Hocevar, JHCC, Joyous!, Ta bu shi da yu, Freakofnurture, Haruo, JimJast, Discospinster, Patricknoddy, Rich Farmbrough, FT2, GeoEvan, Autiger, Paul August, Mehrenberg, Sgeo, Appleboy, RJHall, Mr. Billion, Sfahey, Fenevad, DS1953, Aude, CDN99, Causa sui, Keane4, Bobo192, Smalljim, Davidruben, Viriditas, Richi, Arcadian, Valar, John Fader,
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Nygaard, Kazvorpal, Ceyockey, TigerShark, Nuggetboy, Mhearne, Rikek, Tabletop, Yegorm, Dysepsion, SqueakBox, Graham87, Magister Mathematicae, Bunchofgrapes, Coneslayer, Rjwilmsi, Rogerd, Harro5, Vegaswikian, Oblivious, Ligulem, Cww, Sferrier, Brighterorange, The wub, Dolphonia, Bhadani, M A Mason, Ucucha, Fred Bradstadt, Sango123, Avocado, FlaBot, Ian Pitchford, RobertG, AED,
Nihiltres, Chanting Fox, RexNL, Gurch, Stevenfruitsmaak, BradBeattie, Chobot, Rewster, Gwernol, YurikBot, Koveras, Rob T Firey, Cabiria, Pburka, WAvegetarian, Bergsten, Eleassar, Big Brother 1984, Herbertxu, NawlinWiki, Wiki alf, Bachrach44, Jaxl, Duran,
Irishguy, Albedo, Nephron, Andersonblog, The Filmaker, Wolbo, Voidxor, Tony1, Digitylgoddess, Dissolve, Nescio, Cstaa, WAS 4.250,
Encephalon, JCipriani, Closedmouth, Nemu, Sariberi, Badgettrg, JLaTondre, Spliy, Jacqui M, Ben D., RG2, John Broughton, Andrew73,
Quadpus, SpLoT, SmackBot, Teenwriter, FloNight, Hydrogen Iodide, Pgk, InvictaHOG, Hswapnil, Delldot, Eskimbot, HalfShadow, Xaosux, DaveThomas, Gilliam, ERcheck, Master Jay, RDBrown, W8IMP, Thumperward, DanF, MalafayaBot, SchftyThree, Moshe Constantine Hassan Al-Silverburg, Baa, VenomSnake, Darth Panda, A. B., Scray, Yidisheryid, Pooresd, TheKMan, Wotiuwoetuwte3525,
32GN3B, R0xorz, Fact Checker, Reppppp, Zvar, Krich, Jared, SnappingTurtle, ShaunES, G716, Chandra rippett, Drphilharmonic, Salamurai, Mattopaedia, Kukini, SashatoBot, Lambiam, OhioFred, Kuru, Jidanni, Ninjagecko, Sir Nicholas de Mimsy-Porpington, NongBot,
Rawmustard, Larrymcp, Waggers, SandyGeorgia, Avant Guard, Dl2000, Hu12, Vlad788, Alan.ca, Iridescent, StephenBuxton, Igoldste,
Marysunshine, Tawkerbot2, Ouishoebean, Chitoboy, Jmockbee, Ghaly, Fvasconcellos, SkyWalker, Tifego, JForget, CmdrObot, Eggman64,
Ale jrb, Mattbr, KyraVixen, Trails, GHe, THF, CuriousEric, Edenane, Williamallenmd, Moreschi, Schaber, Cydebot, Psybrdelic, JFreeman, Myscrnnm, DumbBOT, Robbieisfun, MrLenS, IComputerSaysNo, Kozuch, Leendert, Krylonblue83, Casliber, FrancoGG, Mattisse,
Epbr123, Wikid77, Flynnj, Notjake13, Loudsox, Headbomb, Dayn, Laportechicago, Escarbot, Navdar, Eleuther, Dantheman531, Thadius856, PicklePower, Cyclonenim, AntiVandalBot, Majorly, Cwray, Just Chilling, Jayron32, Msnomer, LibLord, Alphachimpbot, Lord
Richard, Richiez, Canadian-Bacon, Res2216restar, JAnDbot, Husond, Instinct, Seddon, Albany NY, Verbivorous, Thebaldbandit, Bennybp, Bongwarrior, VoABot II, Kuyabribri, Lucyin, Jjoshua33, JHB, WhatamIdoing, MiPe, Adrian J. Hunter, Allstarecho, DerHexer,
Khalid Mahmood, Supahfreekeh, Yobol, MartinBot, BetBot, Nicolauswb, Poeloq, Moabalan, Foraminifera, AlexiusHoratius, Nono64,
Fconaway, J.delanoy, Leon math, Numbo3, Maneater**, AlanWolfe, L337 kybldmstr, FrummerThanThou, Mr Rookles, Maestozo, Mikael
Hggstrm, Nsoltani, (jarbarf), Belovedfreak, NewEnglandYankee, Deimel, Gaussgauss, Balaam42, Shoessss, Sunderland06, Timtam85,
Treisijs, Zomguberdude, Billborder, Vinsfan368, Izno, CardinalDan, Idioma-bot, Lights, X!, Deor, Thedjatclubrock, Je G., Mocirne,
MenasimBot, Hehkuviini, Rasillon, Philip Trueman, TXiKiBoT, GimmeBot, Paine, A369852, Medicaldoctor129, Qwertyu123, Gwinva,
Sherrygravely, Melsaran, Gilvala, Madhero88, Ninjatacoshell, Enigmaman, Xianlulaura, Cnilep, Brianga, Jesse1996, Doc James, AlleborgoBot, Heliocybe, RedRabbit1983, EmxBot, SieBot, Winchelsea, Gerakibot, Da Joe, Dawn Bard, Caltas, ConfuciusOrnis, BService,
Micknaor, Exert, Sohelpme, Nopetro, Yerpo, ChrTh, Oxymoron83, Antonio Lopez, Lightmouse, Miguel.mateo, Lumentec, OKBot, Maelgwnbot, MadmanBot, Twigat, Realm of Shadows, Lynnsamal, Dabomb87, Nn123645, JL-Bot, Tattery, The sunder king, Ricklaman,
De728631, ClueBot, The Thing That Should Not Be, Marko sk, Pairadox, Paul Abrahams, Mild Bill Hiccup, Lamasrock, Caboose420,
Zlm73, Osm agha, DrFO.Jr.Tn, Blanchardb, Shannon bohle, Madbeal, Alexbot, CrazyChemGuy, ToNToNi, Rybee824, Keledin, Sun Creator, Tyler, Ravenna1961, NuclearWarfare, Cenarium, Peter.C, Medos2, Razorame, Brianb824, Netanel h, Thingg, Korefauigy, Aitias,
Fatrobbie, UrsaLinguaBWD, SDY, Saguanau101, Saguanau5, Thompsontough, DumZiBoT, BendersGame, Londonsista, Monkey3035,
Tony K10, Infoporn, Fruv, Hard working team, Dwight Burdette, Jkuo3, TamePhysician, Addbot, Emotology, Done3557, Matt641, DOI
bot, Wickey-nl, DougsTech, Older and ... well older, Shokod, D.c.camero, Shayla007, Debresser, Numbo3-bot, 55, Szalax, Walkietalkiee, Ben Ben, Luckas-bot, Yobot, Berkay0652, Uchiha611, MarcoAurelio, THEN WHO WAS PHONE?, Nallimbot, KamikazeBot,
EnTerr, ChildSurvival, Ebalter, Teneil00, Magog the Ogre, AnomieBOT, Piano non troppo, Aditya, Joker1189, Citation bot, Eumolpo,
Lungsunit, LilHelpa, Xqbot, Cureden, Capricorn42, Pneumoniaman123, Hammersbach, Mario123456, Jaxyl, J04n, GrouchoBot, Kevdave,
Soabenke, Ank85, Maria Sieglinda von Nudeldorf, RibotBOT, Thehelpfulbot, Spongefrog, FrescoBot, LucienBOT, Preventpneumo, Citation bot 1, AstaBOTh15, Boulaur, Jonesey95, Sultanofhyd, Thesevenseas, VenomousConcept, Jandalhandler, 9014user, HCUP US,
Da5id1, Jchapple88, TheBearPaw, RjwilmsiBot, Whywhenwhohow, EmausBot, WikitanvirBot, Hreid11, Observer6, , Cpant23,
Drankush, GoingBatty, Uploadvirus, Ceeforcat, Manum56, Lji1942, Jesanj, Kgsbot, CPnieuws, FeatherPluma, Mahmoudalrawi, Will Beback Auto, Mallexikon, Jamesdpalmer, Nijilravipp, Vldscore, EnglishTea4me, Robthepiper, Jcgoble3, Rezabot, JordanSeymore,
, Helpful Pixie Bot, Dalit Llama, Lowercase sigmabot, MKar, Mrjohncummings, Sahara4u, PhnomPencil, Cypella, Neuroschizl,
Je.rrt, FormerNukeSubmariner, Fallingmasonry, RudolfRed, BattyBot, TylerDurden8823, 00AgentBond93, Dexbot, Ildiko Santana, Mogism, Palma Marton Chatonnet, Randykitty, EtymAesthete, Anrnusna, AH999, Captain Cornwall, Monkbot, Formerly 98, TeaLover1996,
Maplestrip and Anonymous: 651

13.2

Images

File:CT_scan_of_the_chest,_demonstrating_right-sided_pneumonia.jpg Source: http://upload.wikimedia.org/wikipedia/commons/

7/7a/CT_scan_of_the_chest%2C_demonstrating_right-sided_pneumonia.jpg License: CC BY-SA 3.0 Contributors: Own work Original
artist: James Heilman, MD
File:Crackles_pneumoniaO.ogg Source: http://upload.wikimedia.org/wikipedia/commons/c/c7/Crackles_pneumoniaO.ogg License:
CC BY-SA 3.0 Contributors: Own work Original artist: James Heilman, MD
File:Gnome-mime-sound-openclipart.svg

Source:

http://upload.wikimedia.org/wikipedia/commons/8/87/

13.3

Content license

15

Gnome-mime-sound-openclipart.svg License: Public domain Contributors: Own work. Based on File:Gnome-mime-audio-openclipart.

svg, which is public domain. Original artist: User:Eubulides
File:Lower_respiratory_infections_world_map_-_DALY_-_WHO2004.svg Source:
http://upload.wikimedia.org/wikipedia/
commons/7/75/Lower_respiratory_infections_world_map_-_DALY_-_WHO2004.svg License: CC BY-SA 2.5 Contributors:
Vector map from BlankMap-World6, compact.svg by Canuckguy et al. Original artist: Lokal_Prol
File:New_Pneumonia_cartoon.jpg Source: http://upload.wikimedia.org/wikipedia/commons/f/fb/New_Pneumonia_cartoon.jpg License: Public domain Contributors: Transferred from en.wikipedia; transferred to Commons by User:Quadell using CommonsHelper.
Original artist: Original uploader was InvictaHOG at en.wikipedia
File:Padlock-silver.svg Source: http://upload.wikimedia.org/wikipedia/commons/f/fc/Padlock-silver.svg License: CC0 Contributors:
http://openclipart.org/people/Anonymous/padlock_aj_ashton_01.svg Original artist: This image le was created by AJ Ashton. Uploaded
from English WP by User:Eleassar. Converted by User:AzaToth to a silver color.
File:Pleural_effusion.jpg Source: http://upload.wikimedia.org/wikipedia/commons/e/e7/Pleural_effusion.jpg License: Public domain
Contributors:
http://www.cdc.gov/ncidod/dvbid/dengue/slideset/spanish/set1/vi/slide08.htm Original artist: User InvictaHOG on en.wikipedia
File:Streptococcus_pneumoniae.jpg Source: http://upload.wikimedia.org/wikipedia/commons/2/20/Streptococcus_pneumoniae.jpg
License: Public domain Contributors: This media comes from the Centers for Disease Control and Prevention's Public Health Image Library
(PHIL), with identication number #262. Original artist:
Photo Credit: CDC/Janice Carr
Content Providers(s): CDC/Dr. Richard Facklam
File:Symbol_support_vote.svg Source: http://upload.wikimedia.org/wikipedia/en/9/94/Symbol_support_vote.svg License: Public domain Contributors: ? Original artist: ?
File:Symptoms_of_pneumonia.svg Source: http://upload.wikimedia.org/wikipedia/commons/2/20/Symptoms_of_pneumonia.svg License: Public domain Contributors: All used images are in public domain. Original artist: Mikael Hggstrm.
File:WPA_Pneumonia_Poster.jpg Source: http://upload.wikimedia.org/wikipedia/commons/7/77/WPA_Pneumonia_Poster.jpg License: Public domain Contributors: Work Projects Administration Poster Collection (Library of Congress). http://memory.loc.gov/service/
pnp/cph/3f00000/3f05000/3f05300/3f05391r.jpg Original artist: WPA Federal Art Project

13.3

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